浅谈病案数字化翻拍的现状

病案数字化翻拍技术是现代病案管理的一种重要技术手段，是医院信息化建设的重要部分。通过对我院近五年病案数字化翻拍技术全面实施情况，分析病案数字化翻拍在病案管理中的现状，及存在的问题，并探讨改进措施。建立起以病案管理人员为主导的全程翻拍质量控制，强化病案数字化的管理环节，保证翻拍质量；进一步提高病案管理的科学性，提升病案管理人员的效率和水平；利用数字化翻拍将电子病历与纸质病案最大限度融合，形成完整、统一的病案管理体系，更安全、高效、合理地利用病案信息资源。

Analysis on the Current Situation of Digital Copying of the Medical Records

Digital copying of the medical records is an important technological means of modern medical records management, and also an important part of the information construction of the hospital. Through studying the full operation situation of digital copying technology in the past five years, we analyzed the current situation of the digital copying in the management of medical records and relevant existing problems, as well as investigated the improvement measures. To establish copying quality control in which the medical records management staff take dominant place, strengthen the management links of medical records digitization, guarantee the quality of copying, improve the scientificalness of medical records management as well as the efficiency and ability of the medical records management staff. With the appli- cation of digital copying, we manage to integrate the electronic medical records and paper medical records to the most limit, and form integrity, united medical management system to take advantage of medical information resource more safety, effective and reasonably.